therapyservicesmanual

Complete Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual

To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Update Log

Publication History

This publication supersedes all previous Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated April 2005, September 2005, December 2015, March 2017, June 2018, August 2017, January 2020 and March 2020.

Update Log

03/26/2020

Added language that services may be performed by a therapy assistant or therapy aide within their scope of practice, but must be billed to Montana Healthcare Programs under the supervising licensed therapist’s NPI.
Removed levels of supervision for speech, occupational and physical therapy aides and assistants as these requirements fall under the purview of the Board of Speech-Language Pathologists and Audiologists, Montana Board of Occupational Therapy Practice, and Montana Board of Physical Therapy Examiners respectively.
Corrected grammatical errors under non-covered services that are not direct member care.
Under Coverage of Specific Services clarified that Telehealth services are available in Montana for Physical Therapy, Occupational Therapy and Speech Therapy.

01/01/2020

Cost Share references removed from the Billing Procedures and How Payment is Calculated Chapters.
Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
Terms "client" and "patient" replaced with "member".

08/29/2017
Manual name changed to Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual.

06/22/2017
Therapy Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

03/29/2017
Therapy Services, April 2017
In summary, the supervision requirements for various types of aides were clarified, telehealth for speech only was added, the cost share sections were updated, Montana Provider Relations, TPL, and Conduent as appropriate replaced Xerox, and the entire manual was prepared for the 508 conversion per the September 2016 Manuals meeting.

12/31/2015
Therapy Services, January 2016: HELP Plan-Related Updates and Others

09/09/2005
Therapy Services, August 2005: Revised Levels of Supervision for Therapists, New Place of Service Codes

04/11/2005
Therapy Services, April 2005: Updated Key Contacts

End of Update Log Chapter

Key Contacts and Websites

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, https://medicaidprovider.mt.gov/, for a list of contacts and websites.

End of Key Contacts and Websites Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization and Maintenance

This manual provides information specifically for physical, occupational, and speech therapy providers. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts and websites on the Contact Us page of the Provider Information website. There is space on the inside of the front cover of this manual to record your NPI/API and CHIP/HMK numbers for quick reference when calling Provider Relations.

Changes to manuals are provided through provider notices and replacement pages. When replacing a page in a manual, file the old pages and provider notices in the back of the manual for use with claims that originated under the old policy.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs program. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. (See the Contact Us link in the left menu on the Provider Information website.) The following rules and regulations are specific to physical, occupational, and speech therapy programs. Additional Montana Healthcare Programs rule references are available in the General Information for Providers manual.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

Administrative Rules of Montana (ARM)
- ARM 37.86.601 – ARM 37.86.610 Therapy Services
Montana Codes Annotated (MCA)
- MCA Title 37, Chapter 11 Physical Therapy
- MCA Title 37, Chapter 15 Speech-Language Pathologists and Audiologists
- MCA Title 37, Chapter 24 Occupational Therapy
Code of Federal Regulations (CFR) 42 CFR 440.110

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The list of contacts on the website has important telephone numbers and addresses. Montana Healthcare Programs manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.

End of Introduction Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services performed by independent physical, occupational, and speech therapists. Therapists that are employed by a facility (e.g., hospitals, nursing facilities, home health agencies) should refer to their corresponding provider manual for requirements and billing procedures, which may vary. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Services within Scope of Practice (ARM 37.86.606)
Services are covered only when they are within the scope of the provider’s license as permitted by state law.

Services Provided by Therapists (ARM 37.86.601–605 and ARM 37.85.402)
Therapy includes speech, occupational, and physical therapy services. Services may be performed by a therapy assistant or therapy aide within their scope of practice but must be billed to Montana Healthcare Programs under the supervising licensed therapist’s NPI. (See the Billing Procedures chapter in this manual.)

Therapy providers must maintain current licensure to practice from the state in which they are practicing. Providers must also be enrolled as Montana Healthcare Programs providers. An assistant or aide may not enroll as a Montana Healthcare Programs provider. Providers cannot submit claims for services they did not provide, except for services provided by therapy assistants or aides. Services performed by an assistant or aide in accordance with Title 37 MCA must have their services billed to Montana Healthcare Programs under the licensed supervising therapist’s Montana Healthcare Programs provider number.

Services Included
Covered therapy services include the following:

Restorative therapy services are ones that are performed with a reasonable expectation that the recipient’s function will improve significantly in a reasonable and predictable period of time, based on and assessment of the recipient’s restoration potential made by the referring physician or midlevel practitioner and the licensed therapist.

Services Restricted

Montana Healthcare Programs does not cover therapy services that are Maintenance therapy. This means therapy that is repetitive and required to maintain functions without a reasonable expectation of significant progress and do not involve complex and sophisticated therapy services requiring the skill of a licensed therapist.

Use the fee schedule for your provider type to verify coverage for specific services.

Non-Covered Services (ARM 37.85.207 and ARM 37.86.606)
Some services not covered by Montana Healthcare Programs include, but are not limited to, the following:

Maintenance therapy services may be covered under the Home and Community-Based Services (HCBS) program; refer to the HCBS manual.
Services that do not require the performance or supervision of a licensed therapist, even if the services are performed by the therapist.
A therapist’s time for the following:
- Attending member care meetings.
- Member-related meetings with other medical professionals or family members.
- Completion of paperwork or reports.
Observation
Acupuncture
Naturopath services
Masseur or masseuse services
Services considered experimental or investigational
Services provided to Montana Healthcare Programs members who are absent from the state, with the following exceptions:
- Medical emergency
- Required medical services are not available in Montana. Prior authorization may be required.
- If the Department has determined that the general practice for members in a particular area of Montana is to use providers in another state.
- When out-of-state medical services and all related expenses are less costly than in-state services.
- When Montana makes adoption assistance or foster care maintenance payments for a member who is a child residing in another state.
Montana Healthcare Programs does not cover services that are not direct member care such as the following:
- Missed or canceled appointments
- Mileage and travel expenses for providers
- Preparation of medical or insurance reports
- Service charges or delinquent payment fees
- Telephone service in home, Remodeling of home, Plumbing service, Car repair and/or modification of automobile

An order/referral is valid for 180 days from the day the therapist receives it.

Verifying Coverage
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the CPT and HCPCS coding books. Use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website.

Therapy Service Requirements (ARM 37.86.606)

Montana Healthcare Programs covers restorative therapy services when they are reasonable and necessary to the treatment of the member’s condition and result in improved function. The amount and frequency of services provided must be within the therapy’s generally accepted standard of practice. Therapy services are not restorative if the member’s expected restoration potential is insignificant in relation to the extent and duration of services required. Therapy services are no longer restorative when it is determined that function will not improve. All therapy services require an order or referral from the member’s physician or mid-level practitioner and documentation on the member’s progress. Some services may also require prior authorization or Passport to Health provider approval before they are provided. See the Prior Authorization chapter in this manual and the Passport to Health manual.

Order/Referral
Therapy services may be provided to a member when a current written or verbal order/referral has been received from the member’s physician or midlevel practitioner. The therapy provider is responsible for obtaining the order/referral before providing services. Montana Healthcare Programs does not cover services provided before obtaining an order/referral. When the order/referral is verbal, the member’s physician or mid-level practitioner must supply the therapist with the same order/referral in writing within 30 days of the verbal order/referral. The therapist should document in his/her records a verbal order/referral was provided by the member’s physician or mid-level practitioner. The written order/referral must be signed and dated by the referring physician or mid-level practitioner. The Department considers an order/referral valid for no more than 180 days from the time the therapist receives the order/referral from the physician or mid-level practitioner. When a member is enrolled in the Passport to Health program, a Passport approval is required and the referral number must be included on the claim. See the Passport to Health manual.

Documentation
Providers must maintain records that demonstrate compliance with Montana Healthcare Programs requirements. General record keeping requirements are described in the General Information for Providers manual, Provider Requirements chapter. All therapy case records must be current and available upon request from the Department. Case records must contain at least the following:

Signed and dated order/referral from the member’s physician or mid-level practitioner.
Member’s name on each page of documentation.
Diagnosis, duration and time, course of treatment, and expected outcomes.
Therapist treatment for each session.
Member’s progress in meeting therapy goals to ensure therapy services are still restorative and not maintenance.
Support time spent for each procedure billed. Time should be indicated in the record, whether a start/end time documented at each visit or total time spent with the member at the visit.
Documentation must be complete and representative of what the therapist has provided each time a member is seen and must support the procedures that are billed to Montana Healthcare Programs.
Records signed and dated by the treating therapist.

Coverage of Specific Services

The following are coverage rules for specific services provided by physical, occupational, and speech therapists. The Montana Healthcare Programs payment includes all related supplies and items used when providing therapy services, except for splints, braces, and slings, which are discussed later.

Augmentative Communications Devices
Montana Healthcare Programs covers augmentative communications devices when they are prior authorized. The Department’s policy is to rent the communications device for eight weeks prior to purchase. For instructions on obtaining prior authorization, see the Prior Authorization chapter in this manual.

Maintenance Therapy Plan
Montana Healthcare Programs covers the development of a maintenance therapy plan by a licensed therapist. The maintenance plan must include all of the following:

The member’s initial evaluation.
Development of a plan that incorporates the prescribing physician’s or mid-level practitioner’s treatment objectives and is appropriate for the member’s capacity and tolerance.
Instructions for others in carrying out the plan and further evaluations by a licensed therapist as required.

Occupational, Physical, and Speech Therapy
Montana Healthcare Programs covers reimburses covered therapies that are ordered by a physician or mid-level practitioner. The order is valid for 180 days. If services are needed past 180 days, a new order must be received and a new care plan must be established. Telehealth services are available in Montana for Physical Therapy, Occupational Therapy and Speech Therapy. All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable so long as such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth.

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program (EPSDT) covers all medically necessary services for children age 20 and under. Therapy services for children are not restricted to a specific number of hours or units as long as the therapy services are restorative, not maintenance. All other applicable requirements apply (e.g., current order/referral, provider requirements, prior authorization requirements, and Passport approval). See the Prior Authorization chapter in this manual and the Passport to Health manual, available on applicable provider type pages on the website.

Splints, Braces, and Slings
Montana Healthcare Programs covers the design, fabrication, fitting, and instruction by a licensed therapist in the use of splints, braces, and slings under the Durable Medical Equipment (DME) program. Therapists must be enrolled with Montana Healthcare Programs as DME providers to bill for these services, and he/she must abide by the rules/policies set forth by the DME program.

Other Department Programs

This is how the information in this manual applies to Department programs other than Montana Healthcare Programs.

Mental Health Services Plan (MHSP)
The information in this manual does not apply to the Mental Health Services Plan (MHSP). For more information on the MHSP program, see the mental health manual available on the Provider Information website.

Healthy Montana Kids (HMK)
The information in this manual does not apply to HMK members. For an HMK medical manual, contact Blue Cross and Blue Shield of Montana at 1 (800) 447-7828. Additional information regarding HMK is available on the HMK website.

End of Covered Services Chapter

Prior Authorization

Therapy services do not require prior authorization. For general information about Prior Authorization, see the General Information for Providers manual.

End of Prior Authorization Chapter

Coordination of Benefits

The following is specific to therapy services. In addition, providers should refer to the section on Third Party Liability in the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

Occupational and physical therapy services provided by independent occupational and physical therapists are covered under Medicare Part B.

End of Coordination of Benefits Chapter

Billing Procedures

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a CMS-1500 claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

on-Montana Healthcare Programs members. Once the relationship is severed, with prior notice to the member either verbally or in writing, the provider may refuse to serve the member.

When Members Have Other Insurance

If a Montana Healthcare Programs member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s healthcare, see the Coordination of Benefits chapter in this manual.

Passport Billing Tips

If you are not the member’s Passport provider, include the Passport provider’s Passport number on the claim.
The member’s Passport provider must be contacted for approval for therapy services to be provided. Using another provider’s Passport number without approval is considered fraud.
For more information on Passport to Health, see the Passport to Health manual.
For claims questions, contact Provider Relations.

Billing for Retroactively Eligible Members

When a member becomes retroactively eligible for Montana Healthcare Programs, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members, attach a copy of the 160-M to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.

When a provider chooses to accept the member from the date retroactive eligibility was effective, and the member has made a full or partial payment for services, the provider must refund the member’s payment for the services before billing Montana Healthcare Programs for the services.

For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges. See the Place of Service Code Set on the CMS website, https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html.

Therapists Employed by Nursing Facilities, Hospitals, or Home Health Agencies

The billing instructions in this chapter apply to independent therapists who bill on professional or CMS-1500 claims. Independent therapists must be individually enrolled Montana Healthcare Programs providers to bill for services. Therapists who are employed by nursing facilities do not need to be individually enrolled in the Montana Healthcare Programs when there services are to be billed by the nursing facility directly to Montana Healthcare Programs. The nursing facility provider will be responsible for meeting the enrollment and billing requirements under the therapy provider number. Therapists that are employed by hospitals or home health agencies should refer to the corresponding provider manual for requirements and billing procedures, which may vary.

Billing for Evaluations

Evaluations are considered an encounter per each code and should be reported as one unit; do not bill with multiple units. If the evaluation spans more than one day, providers should report the day of completion as the date of service when billing.

Coding Tips

Standard use of medical coding conventions is required when billing Montana Healthcare Programs. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. See the Coding Resources table in the General Information for Providers manual. The following suggestions may reduce coding errors and unnecessary claim denials:

Use current CPT, HCPCS, and ICD diagnosis coding books.
Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing.
Attend classes on coding offered by certified coding specialists.
Use the correct “units” measurement on CMS-1500 claims. In general, Montana Healthcare Programs follows the definitions in the CPT and HCPCS billing manuals. One unit may equal one visit or each 15 minutes. Always check the long text of the code description.
When billing for each 15 minutes, one unit of service is equal to 8 minutes but less than 23 minutes. If a single modality or procedure is greater than 23 minutes, then time for more units of service should be counted as follows:

Units Over 23 Minutes

Units: 2 Time: Greater than or equal to 23 minutes, but less than 38 minutes
Units: 3 Time: Greater than or equal to 38 minutes, but less than 53 minutes
Units: 4 Time: Greater than or equal to 53 minutes, but less than 68 minutes
Units: 5 Time: Greater than or equal to 68 minutes, but less than 83 minutes
Units: 6 Time: Greater than or equal to 83 minutes, but less than 98 minutes
Units: 7 Time: Greater than or equal to 98 minutes, but less than 113 minutes
Units: 8 Time: Greater than or equal to 113 minutes, but less than 128 minutes

Count only the time spent treating a member. When counting time, if three modalities are provided and 20 total minutes are spent with the member in providing these services, bill only one unit using the code that best defines the greater amount of the service provided.

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website.

Using Modifiers

Review the guidelines for using modifiers in the CPT, HCPCS, or other helpful resources.
Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.

Always refer to the long description in coding books.

The Montana Healthcare Programs claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
Use modifier 52 when a service or procedure is partially reduced or eliminated. This occurs when a code includes a procedure or service that was not completed, but the code most closely describes the service provided.
Use modifier 22 when a service is more extensive than usual. This modifier can be used when a service is more difficult than usual or when there is an increased risk to the member. Slight extension of the procedure beyond the usual time does not validate the use of this modifier.
The TC modifier is used when only the technical portion of the service is provided. The provider who interprets the results uses modifier 26. When both technical and professional services are performed by the same provider, no modifier is required.

Certain services are covered by Montana Healthcare Programs but have a fee of zero. This means that the service is typically bundled with an office visit or other service (e.g., hot or cold packs). Since the bundled service is covered by Montana Healthcare Programs, providers may not bill the member separately for it.

End of Billing Procedures Chapter

Submitting a Claim

See the Billing Procedures chapter in the General Information for Providers manual.

End of Submitting a Claim Chapter

Remittance Advices and Adjustments

For information on remittance advices and adjustments, see the General Information for Providers manual.

End of Remittance Advices and Adjustments Chapter

How Payment Is Calculated

Overview

Though providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

The RBRVS Fee Schedule

Most services by therapists, physicians, mid-level practitioners, and other providers are paid for using the Department’s Resource-Based Relative Value Scale (RBRVS) fee schedule. The fee schedule includes CPT codes and HCPCS codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not paid for using the RBRVS fee schedule.

RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Healthcare Programs’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Healthcare Programs program, the Department was able to take advantage of the millions of dollars of research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Montana Healthcare Programs, workers’ compensation plans, and commercial insurers.

Many Montana Healthcare Programs payment methods are based on Medicare, but there are differences. In these cases, the Montana Healthcare Programs method prevails.

The following paragraphs elaborate on aspects of the RBRVS fee schedule used by the Department.

Fee Calculation
Each fee is the product of a relative value times a conversion factor.

Basis of Relative Values
For almost all services, Montana Healthcare Programs uses the same relative values as Medicare does in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.

When Montana Healthcare Programs payment differs from the fee schedule, consider the following:

The Department pays the lower of the established Montana Healthcare Programs fee or the provider’s charge
Modifiers. (See Other Modifiers in this chapter.)
Place of service. (See Site of Service Differential in this chapter.)
Date of service. (Fees for services may change over time.)
Also check for Medicare, Incurement or TPL payments shown on the remittance advice.

Composition of Relative Values
For each code, the relative value is the sum of a relative value for the work effort (including time, stress, and difficulty), the associated practice expense and the associated malpractice expense.

Site of Service Differential
The Medicare program has calculated two sets of relative values for each code: one that reflects the practitioner’s practice cost of performing the service in an office and one that reflects the practitioner’s practice cost of performing the service in a facility.

Montana Healthcare Programs typically pays a lower fee than if the service is provided in a facility because typically also pays the facility.

Conversion Factor
The Department sets the conversion factor for the state fiscal year (July through June), and it is listed on the fee schedule.

Policy Adjuster
To encourage access to maternity services and family planning services, the Department increases fees for these codes using a policy adjuster that increases the fee. The fee listed on the fee schedule includes the policy adjuster.

Professional and Technical Components
Many imaging services and some other diagnostic services are divided into the technical component (performing the test) and the professional component (interpreting the test). A practitioner who only performs the test would bill the service with Modifier TC; a practitioner who only interprets the test would bill with Modifier 26; and a practitioner who performs both components would bill the code without a modifier. Performance of both components is called the global service. The fee schedule has separate fees for each component and for the global service.

Other Modifiers
Under the RBRVS fee schedule, certain other modifiers also affect payment.

How Modifiers Change Pricing
The table below shows summary modifier descriptions of modifiers that affect pricing for therapy services. See the CPT and HCPCS coding books for the full text.

Modifiers That Affect Pricing

Modifier: 26 Definition: Professional component
How Payment is Affected: For services paid via the RBRVS fee schedule, see the specific service. For other services, payment equals 40% of the fee.

Modifier: 52 Definition: Reduced service
How Payment is Affected: The service is paid at 50% of the fee.

Modifier: 59 Definition: Distinct procedural service
How Payment is Affected: The service is separate and distinct from another service on the same day. Montana Healthcare Programs will pay both if the modifier is used on one of the codes.

Charge Cap
For the services covered in this manual, Montana Healthcare Programs pays the lower of the established Montana Healthcare Programs fee or the provider’s charge.

Bundled Codes
A few services are covered by the Department but have a fee of zero, meaning that payment for the service is considered bundled into the payment for services that are usually provided with it. Because these services are covered by Montana Healthcare Programs, providers may not bill members for them on a private-pay basis.

Status Codes
The RBRVS fee schedule includes status codes that show how each service is paid. The list of status codes is based on that used by Medicare, as shown in the table.

Medicare and Montana Healthcare Programs RBRVS Status Values

Medicare Status: A - Active code paid using RVUs
Montana Healthcare Programs Status: A - Active code paid using RVUs set by Medicare

Medicare Status: B - Bundled code
Montana Healthcare Programs Status: B - Bundled code

Medicare Status: C - Carrier determines coverage and payment
Montana Healthcare Programs Status: C - Pay by report

Medicare Status: D - Deleted code
Montana Healthcare Programs Status: D - Discontinued code

Medicare Status: E - Excluded from fee schedule by regulation
Montana Healthcare Programs Status: - [Montana Healthcare Programs reviews each code and usually assigns A, K, or X status]

Medicare Status: F - Deleted/discontinued code; no grace period
Montana Healthcare Programs Status: D - [Assigned to D status]

Medicare Status: G - Use another code; grace period allowed
Montana Healthcare Programs Status: G - Use another code; grace period set code-by-code

Medicare Status: H - Modifier deleted
Montana Healthcare Programs Status: - [Assigned to D status]

Medicare Status: I - Use another code; no grace period
Montana Healthcare Programs Status: - [Assigned to G status]

Montana Healthcare Programs Status: J - Anesthesia code

Montana Healthcare Programs Status: K - Active code paid using RVUs set by Montana Healthcare Programs

Montana Healthcare Programs Status: L - Not paid via RBRVS. See lab fee schedule.

Montana Healthcare Programs Status: M - Not paid via RBRVS. See non-RBRVS fee schedule.

Medicare Status: N - Excluded from fee schedule by policy
Montana Healthcare Programs Status: - [Montana Healthcare Programs reviews each code and usually assigns A, K, or X status]

Medicare Status: P - Bundled or excluded
Montana Healthcare Programs Status: - [Montana Healthcare Programs reviews each code and usually assigns B or X status]

Medicare Status: R - Restricted coverage
Montana Healthcare Programs Status: - [Montana Healthcare Programs reviews each code and usually assigns A or K status]

Medicare Status: T - Injections
Montana Healthcare Programs Status: - [Montana Healthcare Programs reviews each code and usually assigns A status]

Medicare Status: X - Excluded from fee schedule by statute
Montana Healthcare Programs Status: X - Not covered

Medicare publishes RVUs for codes that have Medicare status values of R and sometimes publishes RVUs for codes with status values of E, N, or X. Medicare uses the label “injections” for status T but now uses the code for other situations (e.g., pulse oximetry) where Medicare pays for the service only if no other service is performed on the same day.

How Payment is Calculated on TPL Claims

When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability (TPL). In these cases, the other insurance is the primary payer (as described in the Coordination of Benefits chapter of this manual), and Montana Healthcare Programs makes a payment as the secondary payer.

How Payment is Calculated on Medicare Crossover Claims

When a member has coverage from both Montana Healthcare Programs and Medicare, Medicare is the primary payer as described in the Coordination of Benefits chapter of this manual. Montana Healthcare Programs then makes a payment as the secondary payer. For the provider types covered in this manual, Montana Healthcare Programs’s payment is calculated so that the total payment to the provider is either the Montana Healthcare Programs allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called lower of pricing.

End of How Payment Is Calculated Chapter

Appendix A: Forms

For these forms and others, see the Forms link on the Provider Information website.

End of Appendix A: Forms Chapter

Appendix B: Place of Service Codes

For a list of place of service (POS) codes, corresponding names, and a brief description of each, see the CMS website.

End of Appendix B: Place of Service Codes Chapter

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.

2.Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.

3.Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Index Chapter

End of Therapy Services Manual

Update Log

Publication History

This publication supersedes all previous Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated April 2005, September 2005, December 2015, March 2017, June 2018, August 2017, January 2020 and March 2020.

Update Log

03/26/2020

Added language that services may be performed by a therapy assistant or therapy aide within their scope of practice, but must be billed to Montana Healthcare Programs under the supervising licensed therapist’s NPI.
Removed levels of supervision for speech, occupational and physical therapy aides and assistants as these requirements fall under the purview of the Board of Speech-Language Pathologists and Audiologists, Montana Board of Occupational Therapy Practice, and Montana Board of Physical Therapy Examiners respectively.
Corrected grammatical errors under non-covered services that are not direct member care.
Under Coverage of Specific Services clarified that Telehealth services are available in Montana for Physical Therapy, Occupational Therapy and Speech Therapy.

01/01/2020

Cost Share references removed from the Billing Procedures and How Payment is Calculated Chapters.
Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
Terms "client" and "patient" replaced with "member".

08/29/2017
Manual name changed to Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual.

06/22/2017
Therapy Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

03/29/2017
Therapy Services, April 2017
In summary, the supervision requirements for various types of aides were clarified, telehealth for speech only was added, the cost share sections were updated, Montana Provider Relations, TPL, and Conduent as appropriate replaced Xerox, and the entire manual was prepared for the 508 conversion per the September 2016 Manuals meeting.

12/31/2015
Therapy Services, January 2016: HELP Plan-Related Updates and Others

09/09/2005
Therapy Services, August 2005: Revised Levels of Supervision for Therapists, New Place of Service Codes

04/11/2005
Therapy Services, April 2005: Updated Key Contacts

End of Update Log Chapter

Table of Contents

Key Contacts and Websites

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, https://medicaidprovider.mt.gov/, for a list of contacts and websites.

End of Key Contacts and Websites Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization and Maintenance

This manual provides information specifically for physical, occupational, and speech therapy providers. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts and websites on the Contact Us page of the Provider Information website. There is space on the inside of the front cover of this manual to record your NPI/API and CHIP/HMK numbers for quick reference when calling Provider Relations.

Changes to manuals are provided through provider notices and replacement pages. When replacing a page in a manual, file the old pages and provider notices in the back of the manual for use with claims that originated under the old policy. Manual replacement pages and provider notices are posted on the Provider Information website.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs program. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. (See the Contact Us link in the left menu on the Provider Information website.) The following rules and regulations are specific to physical, occupational, and speech therapy programs. Additional Montana Healthcare Programs rule references are available in the General Information for Providers manual.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

Administrative Rules of Montana (ARM)
- ARM 37.86.601 – ARM 37.86.610 Therapy Services
Montana Codes Annotated (MCA)
- MCA Title 37, Chapter 11 Physical Therapy
- MCA Title 37, Chapter 15 Speech-Language Pathologists and Audiologists
- MCA Title 37, Chapter 24 Occupational Therapy
Code of Federal Regulations (CFR) 42 CFR 440.110

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The list of contacts on the website has important telephone numbers and addresses. Montana Healthcare Programs manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.

End of Introduction Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services performed by independent physical, occupational, and speech therapists. Therapists that are employed by a facility (e.g., hospitals, nursing facilities, home health agencies) should refer to their corresponding provider manual for requirements and billing procedures, which may vary. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Services within Scope of Practice (ARM 37.86.606)
Services are covered only when they are within the scope of the provider’s license as permitted by state law.

Services Provided by Therapists (ARM 37.86.601–605 and ARM 37.85.402)
Therapy includes speech, occupational, and physical therapy services. Services may be performed by a therapy assistant or therapy aide within their scope of practice but must be billed to Montana Healthcare Programs under the supervising licensed therapist’s NPI. (See the Billing Procedures chapter in this manual.)

Therapy providers must maintain current licensure to practice from the state in which they are practicing. Providers must also be enrolled as Montana Healthcare Programs providers. An assistant or aide may not enroll as a Montana Healthcare Programs provider. Providers cannot submit claims for services they did not provide, except for services provided by therapy assistants or aides. Services performed by an assistant or aide in accordance with Title 37 MCA must have their services billed to Montana Healthcare Programs under the licensed supervising therapist’s Montana Healthcare Programs provider number.

Services Included
Covered therapy services include the following:

Restorative therapy services are ones that are performed with a reasonable expectation that the recipient’s function will improve significantly in a reasonable and predictable period of time, based on and assessment of the recipient’s restoration potential made by the referring physician or midlevel practitioner and the licensed therapist.

Services Restricted

Montana Healthcare Programs does not cover therapy services that are Maintenance therapy. This means therapy that is repetitive and required to maintain functions without a reasonable expectation of significant progress and do not involve complex and sophisticated therapy services requiring the skill of a licensed therapist.

Use the fee schedule for your provider type to verify coverage for specific services.

Non-Covered Services (ARM 37.85.207 and ARM 37.86.606)
Some services not covered by Montana Healthcare Programs include, but are not limited to, the following:

Maintenance therapy services may be covered under the Home and Community-Based Services (HCBS) program; refer to the HCBS manual.
Services that do not require the performance or supervision of a licensed therapist, even if the services are performed by the therapist.
A therapist’s time for the following:
- Attending member care meetings.
- Member-related meetings with other medical professionals or family members.
- Completion of paperwork or reports.
Observation
Acupuncture
Naturopath services
Masseur or masseuse services
Services considered experimental or investigational
Services provided to Montana Healthcare Programs members who are absent from the state, with the following exceptions:
- Medical emergency
- Required medical services are not available in Montana. Prior authorization may be required.
- If the Department has determined that the general practice for members in a particular area of Montana is to use providers in another state.
- When out-of-state medical services and all related expenses are less costly than in-state services.
- When Montana makes adoption assistance or foster care maintenance payments for a member who is a child residing in another state.
Montana Healthcare Programs does not cover services that are not direct member care such as the following:
- Missed or canceled appointments
- Mileage and travel expenses for providers
- Preparation of medical or insurance reports
- Service charges or delinquent payment fees
- Telephone service in home, Remodeling of home, Plumbing service, Car repair and/or modification of automobile

An order/referral is valid for 180 days from the day the therapist receives it.

Verifying Coverage
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the CPT and HCPCS coding books. Use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website.

Therapy Service Requirements (ARM 37.86.606)

Montana Healthcare Programs covers restorative therapy services when they are reasonable and necessary to the treatment of the member’s condition and result in improved function. The amount and frequency of services provided must be within the therapy’s generally accepted standard of practice. Therapy services are not restorative if the member’s expected restoration potential is insignificant in relation to the extent and duration of services required. Therapy services are no longer restorative when it is determined that function will not improve. All therapy services require an order or referral from the member’s physician or mid-level practitioner and documentation on the member’s progress. Some services may also require prior authorization or Passport to Health provider approval before they are provided. See the Prior Authorization chapter in this manual and the Passport to Health manual.

Order/Referral
Therapy services may be provided to a member when a current written or verbal order/referral has been received from the member’s physician or midlevel practitioner. The therapy provider is responsible for obtaining the order/referral before providing services. Montana Healthcare Programs does not cover services provided before obtaining an order/referral. When the order/referral is verbal, the member’s physician or mid-level practitioner must supply the therapist with the same order/referral in writing within 30 days of the verbal order/referral. The therapist should document in his/her records a verbal order/referral was provided by the member’s physician or mid-level practitioner. The written order/referral must be signed and dated by the referring physician or mid-level practitioner. The Department considers an order/referral valid for no more than 180 days from the time the therapist receives the order/referral from the physician or mid-level practitioner. When a member is enrolled in the Passport to Health program, a Passport approval is required and the referral number must be included on the claim. See the Passport to Health manual.

Documentation
Providers must maintain records that demonstrate compliance with Montana Healthcare Programs requirements. General record keeping requirements are described in the General Information for Providers manual, Provider Requirements chapter. All therapy case records must be current and available upon request from the Department. Case records must contain at least the following:

Signed and dated order/referral from the member’s physician or mid-level practitioner.
Member’s name on each page of documentation.
Diagnosis, duration and time, course of treatment, and expected outcomes.
Therapist treatment for each session.
Member’s progress in meeting therapy goals to ensure therapy services are still restorative and not maintenance.
Support time spent for each procedure billed. Time should be indicated in the record, whether a start/end time documented at each visit or total time spent with the member at the visit.
Documentation must be complete and representative of what the therapist has provided each time a member is seen and must support the procedures that are billed to Montana Healthcare Programs.
Records signed and dated by the treating therapist.

Coverage of Specific Services

The following are coverage rules for specific services provided by physical, occupational, and speech therapists. The Montana Healthcare Programs payment includes all related supplies and items used when providing therapy services, except for splints, braces, and slings, which are discussed later.

Augmentative Communications Devices
Montana Healthcare Programs covers augmentative communications devices when they are prior authorized. The Department’s policy is to rent the communications device for eight weeks prior to purchase. For instructions on obtaining prior authorization, see the Prior Authorization chapter in this manual.

Maintenance Therapy Plan
Montana Healthcare Programs covers the development of a maintenance therapy plan by a licensed therapist. The maintenance plan must include all of the following:

The member’s initial evaluation.
Development of a plan that incorporates the prescribing physician’s or mid-level practitioner’s treatment objectives and is appropriate for the member’s capacity and tolerance.
Instructions for others in carrying out the plan and further evaluations by a licensed therapist as required.

Occupational, Physical, and Speech Therapy
Montana Healthcare Programs covers reimburses covered therapies that are ordered by a physician or mid-level practitioner. The order is valid for 180 days. If services are needed past 180 days, a new order must be received and a new care plan must be established. Telehealth services are available in Montana for Physical Therapy, Occupational Therapy and Speech Therapy. All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable so long as such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth.

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program (EPSDT) covers all medically necessary services for children age 20 and under. Therapy services for children are not restricted to a specific number of hours or units as long as the therapy services are restorative, not maintenance. All other applicable requirements apply (e.g., current order/referral, provider requirements, prior authorization requirements, and Passport approval). See the Prior Authorization chapter in this manual and the Passport to Health manual, available on applicable provider type pages on the website.

Splints, Braces, and Slings
Montana Healthcare Programs covers the design, fabrication, fitting, and instruction by a licensed therapist in the use of splints, braces, and slings under the Durable Medical Equipment (DME) program. Therapists must be enrolled with Montana Healthcare Programs as DME providers to bill for these services, and he/she must abide by the rules/policies set forth by the DME program.

Other Department Programs

This is how the information in this manual applies to Department programs other than Montana Healthcare Programs.

Mental Health Services Plan (MHSP)
The information in this manual does not apply to the Mental Health Services Plan (MHSP). For more information on the MHSP program, see the mental health manual available on the Provider Information website.

Healthy Montana Kids (HMK)
The information in this manual does not apply to HMK members. For an HMK medical manual, contact Blue Cross and Blue Shield of Montana at 1 (800) 447-7828. Additional information regarding HMK is available on the HMK website.

End of Covered Services Chapter

Prior Authorization

Therapy services do not require prior authorization. For general information about Prior Authorization, see the General Information for Providers manual.

End of Prior Authorization Chapter

Coordination of Benefits

The following is specific to therapy services. In addition, providers should refer to the section on Third Party Liability in the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

Occupational and physical therapy services provided by independent occupational and physical therapists are covered under Medicare Part B.

End of Coordination of Benefits Chapter

Billing Procedures

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a CMS-1500 claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

on-Montana Healthcare Programs members. Once the relationship is severed, with prior notice to the member either verbally or in writing, the provider may refuse to serve the member.

When Members Have Other Insurance

If a Montana Healthcare Programs member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s healthcare, see the Coordination of Benefits chapter in this manual.

Passport Billing Tips

If you are not the member’s Passport provider, include the Passport provider’s Passport number on the claim.
The member’s Passport provider must be contacted for approval for therapy services to be provided. Using another provider’s Passport number without approval is considered fraud.
For more information on Passport to Health, see the Passport to Health manual.
For claims questions, contact Provider Relations.

Billing for Retroactively Eligible Members

When a member becomes retroactively eligible for Montana Healthcare Programs, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members, attach a copy of the 160-M to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.

When a provider chooses to accept the member from the date retroactive eligibility was effective, and the member has made a full or partial payment for services, the provider must refund the member’s payment for the services before billing Montana Healthcare Programs for the services.

For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges. See the Place of Service Code Set on the CMS website, https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html.

Therapists Employed by Nursing Facilities, Hospitals, or Home Health Agencies

The billing instructions in this chapter apply to independent therapists who bill on professional or CMS-1500 claims. Independent therapists must be individually enrolled Montana Healthcare Programs providers to bill for services. Therapists who are employed by nursing facilities do not need to be individually enrolled in the Montana Healthcare Programs when there services are to be billed by the nursing facility directly to Montana Healthcare Programs. The nursing facility provider will be responsible for meeting the enrollment and billing requirements under the therapy provider number. Therapists that are employed by hospitals or home health agencies should refer to the corresponding provider manual for requirements and billing procedures, which may vary.

Billing for Evaluations

Evaluations are considered an encounter per each code and should be reported as one unit; do not bill with multiple units. If the evaluation spans more than one day, providers should report the day of completion as the date of service when billing.

Coding Tips

Standard use of medical coding conventions is required when billing Montana Healthcare Programs. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. See the Coding Resources table in the General Information for Providers manual. The following suggestions may reduce coding errors and unnecessary claim denials:

Use current CPT, HCPCS, and ICD diagnosis coding books.
Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing.
Attend classes on coding offered by certified coding specialists.
Use the correct “units” measurement on CMS-1500 claims. In general, Montana Healthcare Programs follows the definitions in the CPT and HCPCS billing manuals. One unit may equal one visit or each 15 minutes. Always check the long text of the code description.
When billing for each 15 minutes, one unit of service is equal to 8 minutes but less than 23 minutes. If a single modality or procedure is greater than 23 minutes, then time for more units of service should be counted as follows:

Units Over 23 Minutes

Units: 2 Time: Greater than or equal to 23 minutes, but less than 38 minutes
Units: 3 Time: Greater than or equal to 38 minutes, but less than 53 minutes
Units: 4 Time: Greater than or equal to 53 minutes, but less than 68 minutes
Units: 5 Time: Greater than or equal to 68 minutes, but less than 83 minutes
Units: 6 Time: Greater than or equal to 83 minutes, but less than 98 minutes
Units: 7 Time: Greater than or equal to 98 minutes, but less than 113 minutes
Units: 8 Time: Greater than or equal to 113 minutes, but less than 128 minutes

Count only the time spent treating a member. When counting time, if three modalities are provided and 20 total minutes are spent with the member in providing these services, bill only one unit using the code that best defines the greater amount of the service provided.

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website.

Using Modifiers

Review the guidelines for using modifiers in the CPT, HCPCS, or other helpful resources.
Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.

Always refer to the long description in coding books.

The Montana Healthcare Programs claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
Use modifier 52 when a service or procedure is partially reduced or eliminated. This occurs when a code includes a procedure or service that was not completed, but the code most closely describes the service provided.
Use modifier 22 when a service is more extensive than usual. This modifier can be used when a service is more difficult than usual or when there is an increased risk to the member. Slight extension of the procedure beyond the usual time does not validate the use of this modifier.
The TC modifier is used when only the technical portion of the service is provided. The provider who interprets the results uses modifier 26. When both technical and professional services are performed by the same provider, no modifier is required.

Certain services are covered by Montana Healthcare Programs but have a fee of zero. This means that the service is typically bundled with an office visit or other service (e.g., hot or cold packs). Since the bundled service is covered by Montana Healthcare Programs, providers may not bill the member separately for it.

End of Billing Procedures Chapter

Submitting a Claim

See the Billing Procedures chapter in the General Information for Providers manual.

End of Submitting a Claim Chapter

Remittance Advices and Adjustments

For information on remittance advices and adjustments, see the General Information for Providers manual.

End of Remittance Advices and Adjustments Chapter

How Payment Is Calculated

Overview

Though providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

The RBRVS Fee Schedule

Most services by therapists, physicians, mid-level practitioners, and other providers are paid for using the Department’s Resource-Based Relative Value Scale (RBRVS) fee schedule. The fee schedule includes CPT codes and HCPCS codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not paid for using the RBRVS fee schedule.

RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Healthcare Programs’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Healthcare Programs program, the Department was able to take advantage of the millions of dollars of research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Montana Healthcare Programs, workers’ compensation plans, and commercial insurers.

Many Montana Healthcare Programs payment methods are based on Medicare, but there are differences. In these cases, the Montana Healthcare Programs method prevails.

The following paragraphs elaborate on aspects of the RBRVS fee schedule used by the Department.

Fee Calculation
Each fee is the product of a relative value times a conversion factor.

Basis of Relative Values
For almost all services, Montana Healthcare Programs uses the same relative values as Medicare does in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.

When Montana Healthcare Programs payment differs from the fee schedule, consider the following:

The Department pays the lower of the established Montana Healthcare Programs fee or the provider’s charge
Modifiers. (See Other Modifiers in this chapter.)
Place of service. (See Site of Service Differential in this chapter.)
Date of service. (Fees for services may change over time.)
Also check for Medicare, Incurement or TPL payments shown on the remittance advice.